Small Animal Ophthalmology

2
 6
1.
2. Limbus
Iris
3. Pupil
4. Lid
2
5. Collarette 2
6. Ciliary body
7. Zonules
8. Lens
9. Vitreous
3
10. Optic nerve
11. EOM
12. Retina
and
tapetum
 Orbit and Globe
Congenital Abnormalities
• Anophthalmia
• Complete absence of the eye
• Extremely rare
• Microphthalmia
• Not uncommon
• Can be unilateral or bilateral
• In less severe form; a small but well developed
eye with normal vision
No treatment is needed
 • Strabismus
– Most pronounced in Siamese
– Develops a convergent strabismus to compensate
of abnormal retinal projection to the brain

• Strabismus (+Lagophthalmos)
– Most common in Pekingnese, Pugs, Boston Terriers

Divergent strabismus

– Treatment for strabismus is not necessary. Lagophthalmos

 Acquired Abnormalities
• Exophthalmos = abnormal protrusion of the eyeball
• Buphthalmos = an enlargement of the eye
• Proptosis = forward displacement of the globe out of
the orbit, usually of traumatic origin
• Lagophthalmos = inability to close the eyelids
completely
• Microphthalmos
• Enophthalmos
• Phthisis bulbi
 Exophthalmos
• abnormal protrusion of the eyeball
 Orbital neoplasia
• Signs
– Exophthalmos with slow onset
– Globe deviation
– Third eyelid protrusion
– Exposure keratitis
– Loss of vision due to optic neuritis
• Diagnosis
– History, biopsy, ultrasound,
MRI, CT
• Treatment
– Remove tumor or exenteration
– In metastatic case, treatment is not practical
 Surgical Procedures
• Exenteration
– Remove the entire orbital contents
– Indication: retrobulbar neoplasm
– Technique is the same as for enucleation, except
extraocular muscle, orbital fat, and other tissues
are removed.
 Proptosis
Most common in brachycephalic breeds
Cause: trauma
Proptosis
• Keep the eye moist and replace the globe
• Initial assessment of the globe
– Eye removal if two or more rectus muscle
avulsion, optic nerve transection, or eyeball
rupture occurs
– Hyphema: repair/ possible remove later
 Proptosis
– Replace globe with positive direct or indirect PLR.
– In doubt and the eye is in good shape, replace it.
• Replacement of the globe
– General anesthesia
– General surgical preparation and eye lubrication
– Replace globe with scalpel handle
– Temporary tarsorrhaphy for 1-2 weeks
 Proptosis
• Medical therapy after replacement of
the globe
– Systemic antibiotics and steroid
– Topical antibiotics qid, atropine sid (and steroid
tid-qid if there is no corneal ulcer)
• Complications
Lagophthalmos
Strabismus

Phthisis bulbi
 Phthisis bulbi
• Shrunken and atrophic globe
• Usually no treatment is needed in dogs unless
irritation
• Consider for enucleation in cats
 Panophthalmitis
• Ocular inflammation involving all coats of the eye.
• Sign: not specific usually with corneal edema, debris
in the anterior chamber, marked congestion of the
conjunctiva, mucopurulent ocular discharge and
blepharospasm.
 Panophthalmitis
• Causes
– Perforating corneal ulcer with intraocular
contamination
– Systemic bacterial or fungal infection
– Proptosis for more than few hour
duration
• Diffuse panophthalmitis: enucleation
 Surgical Procedures
• Enucleation
– Removing the globe, conjunctiva, TE
– Indication: intraocular neoplasm, absolute
glaucoma, severe panophthalmitis, phthisis bulbi
in cats
– Caution: apply very little traction on the optic
nerve, particularly in the cat and bird.
 Surgical Procedures
• Evisceration
– Remove all intraocular contents leaving behind
the cornea and sclera
– Cosmetic procedure with no benefit to the
patient.
EYELID DISEASES
 Congenital Abnormalities
• Eyelid agenesis • Congenital absence of part
or all the layers of an eyelid
• Coloboma: a cleft of fissure
rather than diffuse
• More often in cats
• Treatment: Reconstruction
if needed

20
 Eyelid Agenesis

Eyelid reconstruction

21
Dermoids

- Islands of skin displaced to

an abnormal site
-Treatment: Dissect the dermoid
from the globe

22
Eyelash disease

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Eyelash disease

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 Eyelash disease
• Distichiasis

- Second row of eyelashes, often formed by the openings

of the ducts of meibomian gland
- Districhiasis: More than one cilium growing out of a follicle

25
 Eyelash disease
• Distichiasis
Can cause:
-Ocular irritation with epiphora
-Severe corneal disease due to entropion
-Incidental (most cases)

26
 Distichiasis
• Treatment
– No treatment
– Epilation - regrow
– Electroepilation -
permanent but may cause
cicatricial deformation of the
eyelid electroepilation epilation
– Cryotherapy – apply the
probe to the base of the
meibomian gland and freeze
until the ice ball reaches
the eyelid margin

cryotherap 28
 – Eyelid spliting or wedge resection – cause too much
eyelid deformation
• Complications
– Cilia regrowth, entropion, shortening of the eyelid,
epiphora

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 Eyelash disease
• Ectopic cilia

-Often need magnification to

diagnose
- More serious than distichiasis
- Should be excised
- Topical antibiotic tid-qid (and steroid if no ulcer)
30
 Eyelash disease
• Trichiasis: hairs in abnormal direction causing conjunctival
and corneal irritation

Entropion
Nasal fold
-correction
-removal

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31
 Eyelash disease
• Trichiasis

32
 Ophthalmia neonotorum
- Keratoconjunctivitis occurs before the eyelids separate.
-Swollen orbital area and mucopurulent discharge
at the median canthus

- Gentle retraction. Do not cut with the blade.

- Eye clean and apply antibiotic with steroid if no corneal ulcer
is present.

33
Acquired Abnormalities

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 Diffuse blepharitis

-Numerous causes (Staphylococcosis, parasitic blephaitis,

allergic blepharitis, seborrheic blepharitis, etc,)
- Related to dermal problem
-Treatment: route?

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 Focal lesions
• Chalazion: Granuloma of the meibomian gland
Treatment: Incision over the
conjunctival site, then
remove the mass and currette. Apply
antibiotic and steroid topically

Hordeolum: Bacterial abscess of the eyelid glands

Treatment: Hot, moist compress,

antibiotic systemic and topical,
can express purulent material
manually
36
Eyelid laceration

• Handle as skin wound

• Repair soon
• Two layers suture

37
Surgical repair

38
 Entropion
• Rolling in of the eyelid

Normal Entropion

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 Entropion
Usually causes trichiasis
and corneal lesions

Corneal ulcer

Corneal granualtion 41
Corneal scar
 Entropion
• Types
–Spastic: painful lesion of the globe
( topical anesthesia to rule out)
– Cicatricial: following trauma, surgery, or
inflammation
– Anatomic: congenital or developmental
progress

42
Hotz-celsus

4
3
 Wedge resection

combinati4o4 n
Wedge resection (Full thickness V resection)
Lid tacking for puppies
44
 Ectropion
• Rolling out of the eyelid
– Types • Treatment
• Cicatricial – If the ectropion is causing a
• Senile problem, procedures such
• Anatomic as V to Y technique, full
thickness wedge resection
or eyelid reconstruction
should be performed.

45
 Ectropion
• Surgical technique

V to Y technique

4
7
 Lagophthalmos
• Failure of the eyelids to meet when they are
blinked.
• Causes
– Congenital – predisposition in brachyocephalic dogs
– Facial nerve paralysis
– Secondary:
• Exophthalmos
• Buphthalmos
• Impaired lubrication from KCS

47
Lagophthalmos (cont)

48
Lagophthalmos (cont)
• Treatment
– Congenital predisposition
• topical antibiotic/steroid and artificial tears
– Facial nerve paralysis
• Keep eye moist to see why waiting too see if the
paralysis is temporary
– Secondary
• Keep eye moist until the primary cause resolved
***In all cases that no improvement of the problem,
permanent partial tarsorrhaphy should be
considered.

49
 Symblepharon
• An adhesion of the eyelid (conjunctiva) to the
eyeball.

Usually a complication of infection (esp in kittens after

Herpes conjunctivitis) or superficial neoplasm
Recurrence is frequent after surgical correction
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Eyelid Neoplasia
- Usually benign
- Surgical removal and biopsy
or observation for the problem
in older patient

51
Full thickness V resection

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Advancement flap for partial-thickness lesions

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54
Advancement flap for full-thickness
lesions

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6
Conjunctiva
 Anatomy
• Mucous membrane lining
the eyelid, anterior sclera,
and TE
• Palpebral/Bulbar/Fornix
• Contains globlet cells and
accessorylacrimal glands
 Normal

< conjunctival
problem

Intraocular >
Problem
(episcleral
vessel
congestion)
 Congenital Abnormalities
• Dermoids
Acquired Abnormalities
 Conjunctivitis
• Cause
– Infection (the eye or systemic disease)
Bacteria: There is no cause of bacterial conjunctivitis in dogs.
KCS is No1 cause of bacterial conjunctivitis.
Virus: Herpes
-corneal and conjunctival ulceration,
symblepharon, pseudodiphtheritic
membrane, may sneeze
-intranuclear inclusions, neutrophils
-supportive and symptomatic (any
antibiotic and oral
l-lysine 500 mg PO BID)
 Conjunctivitis (cont)
• Cause
Treat everyone
– Infection (the eye or systemic in the house
disease)
Chlamydia: cat

- Unilateral progressing to bilateral within days

- Intracytoplasmic inclusion body
- Chemosis, thicken and hyperemic conjunctiva
- Epiphora then become mucopurulent OD
becomes mucopurulent discharge, May sneeze
-Treatment terramycin +/-Doxycycline
Mycoplasma: cat
-Usually unilateral
-Small cocci in epithelium
-Mild conjunctival hyperemia
-Serous to mucopurulent OD, occasionally
pseudomembranes occur
-Treatment terramycin or chloramphenicol +/-
 Conjunctivitis (cont)
• Cause
– Infection (the eye or systemic
disease)

• Calicivirus-cat
– Mild to moderate conjunctivitis
– Serous ocular and nasal discharge
– Oral and nasal mucosal ulceration
– Suppportive care /symtomatic therapy
– Usually recover in 7-10 days

Neomycin is usually irritate in cat : Do not use polyoph

 Conjunctivitis (cont)
• Cause (cont)
– Infection (the eye or systemic
disease)

Parasitic
 Conjunctivitis (cont)
• Cause
– Allergies – atopy, food allergy, including
neomycin, pilocarpine, tetracaine
– Physical irritation – FB,
parts of the eyelid
– Eosinophilic
– Toxic
 Conjunctivitis (cont)
• Treatment
– Eliminate causes – FB
– Antibiotics at least 4 times a day
– Steroid: should not be used in viral and mycoplasm infections
– Antihistamine: for allergies
– Cats
• Herpes: idoxuridine and vidarabine are usually ineffective for
conjunctival infection
• Chlamydia: tetracycline for at least 4 weeks +/- Doxycycline
(Chloram also works.)
• Mycoplasma: most antibiotics except neomycin are effective;
treat for 7-10days

– Usually response well. If the signs persist for more than a few
days, re-examine carefully.
 Injuries
• Laceration
• Subconjunctival hemorrhage
– Cause-trauma, clotting disorders
– Treatment – necglet or topical steroid if irritate
 Neoplasia
• Primary conjunctival neoplasm are
umcommon
Third Eyelid
Anatomy
 Structure
• Covered with conjunctiva
• T-shaped cartilage
• Gland surrounding the base of the cartilage
• Lymph follicles

Function
• Protect globe
• Tear secretion
• Distribute the tear film
• Normal movement is passive
• Neoplasm or abscess in the orbit can displace TE

To
examine
 Congenital Abnormalities
• Encircling TE
– Cocker spaniel, beagle
– The conjunctiva of the TE
extends around the globe to various degree
– Usually cause no problem, otherwise surgical
excision can be performed
• Dermoids
– Uncommon. Dissected away if irritating
Acquired Abnormalities
Eversion or inversion of the cartilage

• Can cause, irritation,

conjunctivitis, keratitis,
and epiphora, or no sign
of discomfort
• Treatment: surgical
excision of the affected
cartilage
6/0 Vicryl, PDS, catgut
 TE gland prolapse
• Improper attachment of the TE gland
• May spontaneously
regress and return
repeatedly
• Epiphora and conjunctivitis
may occur
• Treatment: Surgical
replacement
– Morgan pocket technique
– Orbital tacking procedure
Morgan pocket technique

5/0 vicryl, PDS, catgut

TE Protrusion (dog)
• Pain (retractor bulbi reaction)
• Enophthalmos
– Dehydration
– Emaciation
– Microphthalmos
– Phthisis bulbi
• Exopthalmos
• Neoplasia of TE
• Neurogenic
– Horner’s syndrome (idiopathic> 50%)
– Dysautonomia
• Tetanus, Rabies, CDv
• Tranquilizers
Treat the underlying cause
 TE Protrusion (cat)
In general, the same as in dogs

• Follow URI, gastroenteritis, Spirometra or Dipyridium

caninum infection
• Dysautonomia: In young cat may progress to death

• May be self-limiting over 2-8 weeks

 Neoplasia
• Dog-umcommon
– Surgical excision and
biopsy
• Cat
– SCC, Lymphosarcoma
– Surgical excision and
biopsy
6/0 absorable suture
Cornea

85
 Function
• Transmission of light
• Refractive medium of the eye
• Defense – barrier between eye and outside
environment

86
 Anatomy
• Anterior aspect of
A
fibrous tunic of the
globe (0.5 - 0.8 mm
thickness) B
• Layers
– Anterior epithelium (A)
– Stroma (B)
– Descemet’s membrane
(C)
– Endothelium (D) C
D

87
Sequence of corneal vascularization in a
simple injury

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Corneal wound healing
• Epithelial wounds: heals by enlargement and sliding
of adjacent cells
• Stromal wound:
– PMNs invade within a few hours and epithelial cells fill
the
defect. Deeper wounds required stromal deposition.
– Corneal vascularization may occur and remains as ghost
vessel.
– Collagenase for remodeling the cornea before healing.
Excessive collagenase results in corneal melting .

89
90
 Things to look for at the cornea
• Edema
• Blood vessel
• Deposit
• Infiltrate
• Granulation
• Scar
• Pigment
• Foreign material
• Loss of substance
• Fluorescein retention

91
Corneal diagnostic evaluation
• Culture
• STT
• Cytology
• Fluorescein stain

92
 Dermoids

- Normal hair in abnormal location

- Usually at the temporal limbus
- Treatment : keratectomy

93
 Ulcerative keratitis
• Lesions that retain fluorescein dye
• Evaluate for underlying cause
– Eyelid/eyelash abnormalities
– Tear film abnormalities
– Foreign body
– Neuroloic deficit (CN V or VII deficits)

94
 Ulcerative keratitis
• Assessment
– History and clinical cause
– Degree of pain
– Nature of discharge
– Size depth and location
– Extent of vascular response
– Presence of infiltrate, malacia,
– Uveal response

95
ULCER KORNEA
 Ulcerative keratitis
• Simple/uncomplicated (shallow) ulcer

- < 50% depth

- Healed within 1-2 weeks
- Topical broad spectrum antibiotics
- (atropine?, anticollagenase?, systemic antiinflamatory drug?)

97
 Ulcerative keratitis
• Deep ulcer
- > 50% loss of stroma
- Aggressive antibiotic, atropine
- Systemic antiinflamatory drug
- (anticollagenase?)
Surgery to protect the wound and accelerate wound
healing, otherwise intensive monitoring is needed.

98
 Ulcerative keratitis
• Descemetocele
– Stromal loss down to Descemet’s
membrane
– Surgical emergency
– Antibiotics, atropine
– Systemic antiinflamatory drug

99
 Ulcerative keratitis
• Perforation / staphyloma

-Often sealed with fibrin or

iris tissue
-Surgical treatment
-Topical antibiotic and
atropine
-Systemic antibiotics and
antiinflamatory drug

100
 Ulcerative keratitis
• Mealting ulcer
Aggressive antibiotics (gentamycin or
tobramycin every 2 hrs ) Atropine
Anticollagenase Emergency surgery

101
Third eyelid flap; attach to the bulbar conjunctiva

102
Third eyelid flap;
attach to the upper lid

10
4
Tarsorrhaphy – (Stents)
Surgical treatments

TE flap

Tarsorrhaphy

106
CONJUNCTIVAL FLAP
 Complicated corneal ulcer
• Complicated corneal ulcer
– Bacterial corneal ulcer
– Viral keratitis
– Mycotic keratitis
– KCS
– Lagophthalmos
– Abnormalities of eyelash
– FB

108
CORNEAL PUNCTURE/CAT SCRATCH
 Corneal laceration
• Emergency Sx
• Flushing with sterile balance
salt
• Less than 2-3 hrs and iris in good
condition: reposition and corneal
suturing
• > 2-3 hrs: excise the prolapsed portion
and corneal suturing
• Large amount of necrotic iris protruding:
with no PLR to the opposite eye:
enucleation

109
 Corneal abscess
• Healed ulcer with an infection beneath
• Topical antibiotics if not response: corneal
scraping and culture.

110
Corneal sequestrum
• Persian, Himalayan, Burmese, and Siamese
cats are predisposed
• Associated with chronic irritation
(conformation abnormalities or FHVI)

111
 Lens

Cataract

112
 Definition of cataract
Opacity in the normally transparent crystalline lens

115
http://www.najafimd.com/e-cataract.html http://321eyes.com/cataract.htm http://www.agape1.com/cataract.htm
 Diagnosis
1. Dilate pupil with 1% tropicamide

116
2.Retroillumination

12/3

117
3 Slit lamp

118
 Differential Diagnosis

Nuclear Sclerosis Cataract

11
9
 Cataract classification
1. Cause • #1 cause of cataract in
– Inherited (~<6 Y) Dog: Inherited
– Senile (~>6 Y)
– Metabolic
• DM
• Milk replacer
• Hypocalcemia
– Uveitis
– Trauma
– Toxic Cat: Uveitis
• Ketoconazole
• Retinal degeneration
– Ionizing radiation
– Electric shock
– Secondary to PRA

118
 Diabetic cataract

Glucose (aldose reductase ) Sorbital

accumulate within lens Both eyes cataract
Intumescent
Rapidly progressive sorbital
water imbibition
Y-sutures separate due to fluid accumulation in lens
119
 Cataract classification
2. Age of onset
– Congenital
• Inherited (Miniature Schnauzer, Boston Terrier, Old Engligh Sheepdog,
Welsh Springer Spaniel, and West Highland White Terrier)
• In utero event
• Milk replacer
– Juvenile
• Inherited
– Senile
• Age-related degenerative disease

120
 Cataract classification
3. Location of cataract

http://www.dogstuff.info/lens_anatomy_kral.html 123
 Cataract classification
4. Stage of cataract Incipient

• <10-15%
• Smoky
• Anterior lens capsule
smooth
• Normal anterior
chamber depth
• Tapetal reflection:
present

122
 Cataract classification
4. Stage of cataract Immature/Incomplete

• > 10-15, <100%

• Smoky
• Anterior lens capsule smooth
• Normal anterior chamber
depth
• Tapetal reflection: present

123
 Cataract classification
Mature/Complete
4. Stage of cataract

• 100%
• Smoky
• Anterior lens capsule
smooth
• Normal anterior
chamber depth
• Tapetal reflection:
absent

124
 Lens Removal

Intracapsular Extracapsular Phacoemulsification With

lens extraction lens extraction Irrigation/Aspiration

Tx: Lens luxation Tx: cataract extraction

Rarely performed Tx: cataract extraction

127
http://www.cureblindness.org/cataracts/techniques.html
 Cataract Management
• DM – control blood sugar before lens surgery
• Monitor
– the progression of cataract stage
(Sx during immature stage –higher success rate than
mature and hypermature stage)

126
 Cataract Surgery
– No dazzle/No PLR : No hope for vision
– Incipient or immature cataract : Menace response should
remain.
– Eyes with hypermature cataract is associated with a lower
success rate
– If you are not sure, refer when cataract are first noticed

127
 Cataract patient selection
• Eye condition
– No other vision threatening conditions; uveitis,
glaucoma

130
http://health.nytimes.com/health/guides/disease/cataract/
Cataract patient selection
• Ultrasound

• ERG
129
Cataract patient selection

• General health of animal

• Temperament of the animal
• Client commitment

“Eye, Pet, Owner: must be good to be a

good candidate”

130
 Conclusion
• Differentiate nuclear sclerosis from cataract
• In any cases of cataract, dogs with no PLR and no
dazzle are not good candidates
• Cataract management by monitoring of cataract
stage
• DM case – monitor glucose level before Sx
• Early surgery gives a better result

131
Glaucoma

http://www.pbase.com/jandrade/image/75960548
 Glaucoma
• A group of diseases united by a common
theme in which IOP is too high for the optic
nerve to function properly resulting the lost of
some or all vision
 Dog breeds most commonly affected
by glaucoma
• Open angle • Closed angle • Secondary
– Mixed breed – American Cocker – Mixed breed
– American – Mixed breed – American Cocker
Cocker – Basset Hound – Wired Haired
– Basset Hound – Samoyed
– Boston Terrie Fox Terrier
– Beagle
– Miniature – Toy Poodle
– Siberian Husky
Schnauzer – – Boston Terrier
Chow Chow
– Beagle – Wire Haired Fox – Miniature Poodle
Terrier – Labrador retriever
– Toy Poodle – Siberian Husky
– Standard – Basset Hound
Poodle – Beagle
GLAUCOMA
NORMAL
OPEN ANGLE
CLOSE ANGLE
Acute signs of glaucoma
Corneal edema

Mydriasis

Pain

Visual deficit

Episcleral vessel congestion (red eye)

Chronic signs of glaucoma
Variable acute signs

< Haab’s striae

Exposure keratitis >

< Buphthalmos
Chronic signs of glaucoma

Lens luxation/
subluxation
Cataract >

< Scleral thining/

staphyloma

Phthisis bulbi
>
 Diagnosis of glaucoma
 Signalment, history, and clinical signs

 Tonometry
 Diagnosis of glaucoma
 Gonioscop
y
Open Closed Angle
Angle
 EFFECT OF GLAUCOMA
Episcleral vessel
Optic nerve
congestion
head cupping

Gangloin cell death Corneal edema

Endothelial damage
Haab’s striae
Pupil dilate
Lens luxation/
subluxation
Decrease aqueous secretion
Staphyloma
Cataract

Buphthalmos Exposure keratitis

http://adam.about.com/reports/000026_7.htm
DIFFERENCE ACUTE AND CHRONIC
GLAUCOMA
 Secondary glaucoma

Anterior lens luxation Anterior Uveitis

Hyphema Neoplasia Complete anterior synechia

THERAPY
1. PgF2α derivate (Latanoprost,
Travoprost, Bimatoprost)
2. Hyperosmotik agent (Manittol dan
Glycerine)
3. Carbonic Anhydrase Inhibitors
(Dorsolamide, Brinzolamide)
4. Cholinergic (Pilocarpin)
5. Β-Adrenergic Blockers(Timolol,
Betoxalol)
MANAGEMENT OF ACUTE GLAUCOMA
 EAR DISEASE
1. CONGENITAL DZ OF THE EAR
2. INFLAMMATORY DZ OF THE EAR
3. INFLAMMATORY DZ OF THE EXT. EAR
CANAL
4. INFLAMMATORY DZ OF THE MIDDLE EAR
5. TRAUMA OF THE AURICLE
DIAGNOSTIC

1. STANDART DIAGNOSIS
2. OTOSCOPE
3. SPECIAL DIAGNOSTIC TECHNIQUE
OTOSCOPE
OTOSCOPE
OTOSCOPE
OTOSCOPE
CONGENITAL DZ OF THE EAR

1. CONGENITAL DEAFNESS
2. CONGENITAL DEFORMITY OF THE EXT. EAR
INFLAMMATORY DZ OF THE EAR

PRIMARY AND SECONDARYSKIN DZ OF THE AURICLE :

1. Contact hypersensitivity
2. Parasites
3. Keratinization disorder
4. Leishmaniasis
5. Alopesia
6. Immune-mediated disorders
INFLAMMATORY DZ OF THE EXT.
EAR CANAL
1. Acute otitis externa – Foreign bodies
2. Acute otitis externa – Ear mites
3. Acute diffuse bacterial otitis externa
4. Chronic otitis externa
5. Chronic proliferative otitis externa
6. Chronic bacterial otitis externa
7. Complication of otitis externa
INFLAMMATORY DZ OF THE MIDDLE
EAR
1. Otitis media ± effusion
2. Horner’s syndrome
3. Labyrinthitis
4. Chronic otitis media
TRUMA OF THE AURICLE